Provider Demographics
NPI:1215319793
Name:ORLANDO SKIN INSTITUTE, LLC
Entity type:Organization
Organization Name:ORLANDO SKIN INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:386-742-0419
Mailing Address - Street 1:110 POND CT
Mailing Address - Street 2:STE 301
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713
Mailing Address - Country:US
Mailing Address - Phone:386-742-0419
Mailing Address - Fax:386-742-4119
Practice Address - Street 1:110 POND CT
Practice Address - Street 2:STE 301
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713
Practice Address - Country:US
Practice Address - Phone:386-742-0419
Practice Address - Fax:386-742-4119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4781207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty